“mad about science, technology, engineering and math” · “mad about science, technology,...

Workshops include:

“Mad About Science, Technology, Engineering and Math”

Saturday, February 20, 2010 at University of Washington Bothell

● Robotics ● Gaming ● Engineering ● Presenters from DigiPen, Microsoft X-Box, First Pacific Robotics, and many more!

Register Now! Complete the registration materials and return them to the HERO Advisor at your

school or send them to the address listed in the registration form.

For more information: Contact Jordan Svien, HERO Program Associate, at 1.877.655.4097

HERO Institute University of Washington Bothell

Saturday, February 20, 2010 9:00am — 4:30pm

Please return the completed form to the College Success Foundation by Monday, February 1, 2010

College Success Foundation: 1605 NW Sammamish Rd. Ste. 200, Issaquah, WA 98027

Toll Free Number: 1-877-655-4097

HERO Institute Registration Form Name: ___________________________________________ School: Mailing Address: City, State, Zip: Sex: M F (Circle One) Grade: ______ Home Phone: ( ) Email Address: I understand that participation in the HERO Institute is required as part of my participation in the HERO Program and is offered at no cost to me and/or my parents/guardians if they are able to attend.

___________________________________ ________________________ HERO Student Signature Date of Birth Date

*Important Note: This year’s program will begin at University of Washington Seattle. After the opening ceremonies, students will be transported to University of Washington Bothell. Parents/guardians who are driving to the Institute may drive to UW Bothell after the opening or ride on the provided bus. After the program at UW Bothell concludes, there will be buses returning to UW Seattle. All bus transportation is provided free of charge.

Please check the appropriate box based on your family attendance and transportation needs:

If you will be attending with your parents/guardians, please list who will be attending with you:

Name: __________________________________________ Relationship:




X HERO Institute Selection Additional Directions

___ I will attend with my family and will require transportation.

Please check in with your HERO Advisor regarding departure and travel information.

___ I will attend with my family but will not require transportation.

Please indicate how you will arrive at University of Washington Seattle for this event _______________________________________________.

___ I will attend without my family and will require transportation.

Please check in with your HERO Advisor regarding departure and travel information.

___ I will attend without my family but will not require transportation.

Please indicate how you will arrive at University of Washington Seattle for this event: ______________________________________________.

HERO Participant Information and Contact Form

HERO Student Information:

Name: ____________________________________________ Home Phone: ( )

Mailing Address:

City, State, Zip:

Medical or Mobility Restrictions:

Current Medications or Special Needs:

Allergies:

Physician's Name: ___________________________________ Phone:

Parent /Guardian Information:

Name: ____________________________________________ Home Phone: ( )

Address:

Parent Work Phone: ( ) ______________________ Parent Cell Phone: ( )

If unable to reach parent, please contact:

Name and Relationship: Phone: ( )

If I cannot be reached, I authorize the Program’s representatives to secure such emergency services for my child as they deem necessary.

I further understand that my child’s selection as a HERO participant may involve coverage by the media. I agree that the Program, the Foundation, the CSF and University of Washington Bothell may use my child’s name, image, voice, or likeness in connection with publicity for the HERO Program Initiative.











HERO Parent/Guardian Consent for Program Participation, Medical Care, and Photographic/Video Release Form

My child, _____________________________________, has my permission to participate in the HERO Institute with the College Success Foundation, February 20, 2010. I release the HERO Program Initiative (“HERO”), the Bill & Melinda Gates Foundation (“the Foundation”), the College Success Foundation, University of Washington Bothell ("UWB"), and their respective directors, officers, agents, and employees (collectively, “Releasees”) from liability for any loss, damage, injury or illness resulting from my child’s participation in this event (including, but not limited to, all program activities and all provided transportation). On behalf of my child and myself, I promise that I will not institute, prosecute, or in any way aid in the prosecu-tion of any claim, demand, action, or cause of action against the Releasees or any of them. I remain fully respon-sible for any actions taken by my child. In the case of injury or illness, I authorize Program representatives to seek all necessary medical attention for my child. I hereby authorize and give consent to any licensed physician or health care provider, to perform upon or administer treatment to the above-mentioned child any reasonably necessary medical treatment. This authoriza-tion is intended to cover emergency treatment, injections, and minor procedures. I also give permission to admin-ister whatever anesthetic may be necessary or advisable during a medical procedure. This permission is good only while the student is participating in the HERO Institute. In such case, I understand that I will be notified as soon as possible and that my insurance carrier or I am responsible for any and all medical expenses incurred. I further understand that my child’s selection as an HERO participant may involve coverage by the media. I hereby release any claim I may have surrounding rights to my child’s name, image, voice, or likeness, and I agree that the Program, the Foundation, the College Success Foundation and UWB may use my child’s name, image, voice, or likeness in connection with publicity for the HERO Program Initiative. I verify that I have read and understood all three pages of this document and agree to its terms.

Signed this ______ day of ____________, 20____ at _____________________, Washington.

Day Month Year City ________________________________ _______________________________ Student Name Student’s Date of Birth ________________________________ _______________________________ Parent/Guardian (Print Name) Parent/Guardian (Signature)

“mad about science, technology, engineering and math” · “mad about science, technology,...

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